How should I manage an elderly patient (≥65 years) with ankle pain, a normal plain‑film X‑ray, and a mild anterior ankle joint effusion on ultrasound?

Management of Elderly Patient with Ankle Pain, Normal X-ray, and Mild Anterior Joint Effusion

In an elderly patient with ankle pain, normal radiographs, and mild anterior ankle effusion on ultrasound, initiate conservative management with NSAIDs (or acetaminophen if NSAIDs are contraindicated), functional rehabilitation including proprioceptive training, and obtain MRI without IV contrast if pain persists beyond 6 weeks to evaluate for occult osteochondral lesions, ligamentous injury, or soft-tissue pathology. 1, 2

Initial Conservative Management (First 6 Weeks)

Pharmacologic Treatment

• Start with acetaminophen up to 4 grams daily as first-line analgesic, particularly in elderly patients to avoid NSAID-related complications including gastrointestinal bleeding, renal dysfunction, and cardiovascular risks. 1
• If acetaminophen provides insufficient relief, consider topical NSAIDs before oral NSAIDs to minimize systemic exposure and side effects. 1
• When oral NSAIDs are necessary, use the lowest effective dose for the shortest duration, with mandatory co-prescription of a proton pump inhibitor in elderly patients given their substantially higher risk of GI bleeding (most fatal GI events from NSAIDs occur in geriatric populations). 1, 3
• COX-2 inhibitors may be considered but require caution as rofecoxib causes fluid retention in older adults and carries increased cardiovascular risk without concurrent aspirin. 1

Functional Rehabilitation Protocol

• Implement early mobilization with external support (semirigid ankle brace or lace-up support) rather than immobilization, as immobilization causes joint stiffness, muscle atrophy, and proprioceptive loss. 2, 4, 5
• Prescribe neuromuscular training and proprioceptive exercises, which have moderate evidence for decreasing functional instability and minimizing re-injury risk. 4
• Include progressive weight-bearing as tolerated, local muscle strengthening, and general aerobic fitness training as core non-pharmacologic interventions. 1, 2
• Manual therapy techniques (manipulation and stretching) improve ankle dorsiflexion and should be incorporated. 1, 4

Adjunctive Measures

• Apply local heat or cold applications for symptomatic relief. 1
• Consider assistive devices (walking stick) if the patient has specific problems with activities of daily living. 1
• Recommend shock-absorbing footwear to reduce joint stress. 1

Advanced Imaging if Pain Persists Beyond 6 Weeks

MRI Without IV Contrast (Preferred)

• MRI is the imaging modality that globally evaluates all anatomic structures including ligaments, tendons, cartilage, and bone, and is particularly useful for soft-tissue abnormalities. 1, 2, 6
• MRI has high accuracy for detecting occult osteochondral lesions, ligamentous tears, and tendon abnormalities that are not visible on plain radiographs. 1, 2
• The presence of mild anterior joint effusion suggests underlying intra-articular pathology that may be occult on radiographs, including cartilage injury, synovitis, or impingement lesions. 1, 7

Alternative: CT Without IV Contrast

• CT is an equivalent alternative if MRI is contraindicated (pacemaker, severe claustrophobia, metallic implants). 1
• CT better visualizes cortical and subcortical bone involvement and intra-articular ossific bodies. 6

Specific Pathologies to Consider Based on Imaging

Occult Osteochondral Lesions

• If MRI reveals osteochondral lesions, symptomatic lesions may require arthroscopic excision or repair, particularly lateral talar lesions which may have different clinical outcomes. 2, 6, 7
• Conservative management with immobilization and radiographic follow-up is appropriate for small, stable lesions. 2

Ligamentous Injury

• Grade the severity of any ligamentous injury (1,2, or 3) as this determines treatment approach, particularly for syndesmotic, anterior talofibular, and deltoid ligament injuries. 6
• Severe ligament injuries may require surgical consideration after adequate rehabilitation trial. 2

Impingement Syndromes

• MRI can identify synovitis and impingement lesions contributing to chronic symptoms. 1
• Surgery is recommended for refractory cases of impingement syndrome after conservative measures fail. 7, 8

Tendon Pathology

• Peroneal tendon injury or flexor hallucis longus tenosynovitis should be treated conservatively before surgery is considered. 7, 8

Interventional Options for Refractory Pain

Intra-articular Corticosteroid Injection

• Consider intra-articular corticosteroid injection (e.g., triamcinolone hexacetonide) for moderate to severe pain, especially when evidence of inflammation and joint effusion exists. 1, 8
• This is particularly beneficial for acute exacerbations in patients where oral NSAIDs are contraindicated. 1

Hyaluronic Acid Injection

• Intra-articular hyaluronic acid has shown efficacy for pain not adequately relieved with non-invasive therapies, though this is better established for knee osteoarthritis. 1

Opioid Analgesics (Last Resort)

• For severe refractory pain, carefully titrated opioid analgesics may be preferable to high-dose NSAIDs in elderly patients given the substantial risks of NSAIDs in this population. 1
• In elderly patients over 75 years, total tramadol dose should not exceed 300 mg/day. 9

Critical Pitfalls to Avoid

• Do not rely on clinical examination alone in the first 48 hours, as excessive swelling and pain limit accurate assessment of ligament integrity. 10, 2
• Do not miss syndesmotic (high ankle) injuries, which require different management and have longer recovery times; test with the crossed-leg maneuver. 10, 2
• Avoid immobilization, which results in joint stiffness, muscle atrophy, and loss of proprioception. 5
• Do not initiate overly aggressive rehabilitation before adequate healing, as this can lead to displacement or progression of instability. 10, 6
• Monitor renal function when prescribing NSAIDs in elderly patients, as they are at greater risk for NSAID-induced renal toxicity and naproxen is substantially excreted by the kidney. 3
• Recognize that elderly patients tolerate peptic ulceration or bleeding less well than younger patients, making NSAID selection and gastroprotection critical. 1, 3

Surgical Referral Indications

• Failure of conservative treatment after adequate 6-8 week rehabilitation trial. 1, 10
• Progression to moderate or severe instability on repeat stress testing. 10
• Large associated fracture fragments (>15mm). 10
• Development of chronic ankle instability with persistent symptoms despite rehabilitation. 10, 11